A nurse is caring for a client who has a history of angina.
Select all that apply.
Blood pressure
Anxiety
Oxygen saturation
Breath sounds
Irregular heart rate
Chest tightness
Correct Answer : A,B,E,F
A. The client’s BP increased significantly from 150/80 to 180/86 mm Hg, which can indicate increased cardiac workload or evolving cardiac ischemia.
B. Anxiety in this context may be a sign of worsening cardiac status or an early symptom of myocardial infarction (MI).
C. The oxygen saturation is 95%, which is within normal limits and not concerning at this point.
D. Breath sounds are clear and unchanged from the earlier assessment, suggesting no immediate respiratory compromise.
E. The heart rate became irregular and increased to 112/min, which could indicate a dysrhythmia or cardiac ischemia.
F. Chest tightness radiating to the jaw and not relieved by rest is a classic sign of myocardial infarction and should be treated as a medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.While high blood glucose levels are concerning, the threshold for notifying the provider typically starts at 240 mg/dL, especially if ketones are present. However, testing for ketones is the more immediate action during illness.
B.Insulin should not be withheld during illness, even if nausea is present, because illness can increase blood glucose levels and the risk of diabetic ketoacidosis.
C.Fluids should be encouraged during illness to prevent dehydration, not limited.
D.Testing urine for ketones during illness is essential in children with type 1 diabetes, as it helps detect early signs of diabetic ketoacidosis and guide further treatment.
Correct Answer is ["A","B","E","F"]
Explanation
A. The client’s BP increased significantly from 150/80 to 180/86 mm Hg, which can indicate increased cardiac workload or evolving cardiac ischemia.
B. Anxiety in this context may be a sign of worsening cardiac status or an early symptom of myocardial infarction (MI).
C. The oxygen saturation is 95%, which is within normal limits and not concerning at this point.
D. Breath sounds are clear and unchanged from the earlier assessment, suggesting no immediate respiratory compromise.
E. The heart rate became irregular and increased to 112/min, which could indicate a dysrhythmia or cardiac ischemia.
F. Chest tightness radiating to the jaw and not relieved by rest is a classic sign of myocardial infarctionand should be treated as a medical emergency.
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